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Okaloosa EMS Customer Satisfaction Survey
Please provide some information regarding when Okaloosa County EMS services were used.
Date of Service
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
What is the patient's age?
Under 18
18 - 30
31 - 44
45 - 54
55 - 64
65 or older
What is the patient's gender?
Female
Male
Prefer not to disclose
Prefer to self describe:
This survey is completed by:
Patient
Parent/Guardian
Spouse
Other Family
Other Caregiver
What were the circumstances requiring Okaloosa County EMS services?
Illness or injury requiring a 911 call
Transfer from one hospital to another hospital
Transport from the hospital to a nursing home, assisted living facility, or residence
Transport from and/or to a doctor's or dialysis appointment
Other (please specify)
